Amanda Holm

Friday, March 26 1999

Thank you Amanda for accepting our " rendez-vous ". May I ask you to introduce yourself ?

I am a graduate of the University of Michigan, with a B.A. in psychology and an MPH in Health Behavior/Health Education. I started working in tobacco control almost two years ago, when I accepted my current position with the National Association of County and City Health Officials to work on their Tobacco Prevention and Control Project.

I started working with NACCHO just a few weeks after the original "June 20"
agreement was announced by the State Attorneys General and the tobacco industry, so as you might guess I got to jump into the field feet first.

1. Can you tell us about NACCHO's Tobacco Prevention and Control Project?
When and why did it start?
How is it organized?
What are your main activities?

The history of NACCHO's Tobacco Prevention and Control Project (TPC Project for short) is intertwined with the history of NACCHO as an organization. NACCHO was created through the merger of the NationalAssociation of County Health Officials (NACHO) and the U.S. Conference of Local Health Officials (USCLHO) several years ago.

Prior to that time there had been an Advisory Committee on tobacco issues within NACHO, but the work done by that Committee received no funding.

A while after the merger, NACCHO entered into a Cooperative Agreement with the U. S. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH), which provides funding for staff support to deal with tobacco issues as well as some programmatic activities.

It has been funded for the past 3 years or so, and has steadily expanded over the course of its existence.

As noted above, I'm the program manager for the project, so I provide the main staff support. My work is overseen by the NACCHO Tobacco Prevention and Control Committee, a group of eight local health officials (heads of local health departments) from around the U.S. who have interest, expertise and experience in local tobacco control.

In a broad sense, the project's main activity is to keep local health officials informed about the resources available to them from CDC-OSH, other federal agencies, and national non-profits--educating the educators, so to speak.

We do this mostly through our newsletter publications--NACCHO News, which goes out to the approximately 3,000 local health departments in the country, Membership Monthly, which is sent to the roughly 1,000 local health officials who are members of NACCHO, and the NACCHO Special Report, which is a biannual newsletter sent to all local health departments that deals specifically with trends and current issues in tobacco control.

Some GlobaLink participants may have received copies of the Special Report, or of NACCHO's Tobacco Use Prevention and Control Handbook, published last year.

NACCHO also has a Web site which includes tobacco control information, which we are currently overhauling to allow us to keep the information more current.

Other activities include the annual Champion for Tobacco-Free Youth Award, which is presented each year to NACCHO members whose local health department has done outstanding work in the field of local tobacco control.

We also typically include at least one tobacco-related session at NACCHO's Annual Conference, to provide further educational opportunities for members.

We recently began work on a project in collaboration with CDC-OSH, Americans for Nonsmokers' Rights (ANR), the Robert Wood Johnson Foundation, and the National Association of Local Boards of Health, to document local tobacco control ordinances in the U.S.

This year we plan to pilot a survey in several states that will ask local health officials whether their locality has a local ordinance, and if so, request that they send a copy of the ordinance(s) to ANR. ANR has already done extensive work in tracking local ordinances and would like to make their database of these regulations comprehensive and complete.

We hope to work with these partners over the next few years to track local ordinances across the nation.

2. I have read about tobacco control projects in San Francisco and we spoke recently about the City of Philadelphia considering suing the tobacco manufacturers about cigarette induced fires. I assume there is a big variety of tobacco control initiatives managed by cities and counties, could you give us a rÈsumÈ of the principal ones?

You certainly assume correctly! Cities and counties get involved in virtually every aspect of tobacco control, because the local community is where the rubber meets the road in public health. As you mention, several localities are still contemplating lawsuits against the industry for a variety of reasons.

But there are many other activities on which local health officials and their health department staff work, including:

--educating policymakers about the need to restrict smoking in public places, limit advertising, or keep minors from accessing tobacco products;

--enforcing regulations, particularly youth access laws, licensing of tobacco vendors, and Synar statutes;

--educating tobacco retailers about youth access issues to encourage voluntary compliance;

--educating restaurant, bar, and other "public venue" owners about secondhand smoke to encourage voluntary smokefree policies;

--coordinating mass media educational campaigns (counter advertising);

--providing expertise and technical assistance to community groups;

--helping to support and design State policies to prevent and control tobacco use (excise tax increases, youth access laws, and so on);

--working with schools on programs to prevent youth smoking;

--providing health education and smoking cessation opportunities for adults and youth (and training others to provide these services);

--coordinating youth involvement in anti-tobacco activities;

--conducting surveillance and evaluation activities to monitor the success of prevention efforts;

--participating in national publicity events, such as Kick Butts Day and the Great American Smoke Out...

...and the list could go on.  I'm constantly amazed by the creative programs coming out of localities across the country.

3. Are there parts of the US where the local tobacco control initiatives are much more frequent?
One would expect the states where referenda were passed to be more active and states with tobacco "interests" (growers and/or manufacturing plants) to be more reluctant?

Obviously there's a great deal of variation between states in terms of levels of tobacco control activities.

As you suspect, states such as California, Massachusetts, Oregon, Minnesota, and Arizona are among the more active ones. Florida has burst onto the scene recently, though its program looks imperiled by politics right now.

But there are also some that you wouldn't expect: Kentucky and North Carolina, for example, have strong coalitions despite their tobacco-growing and -manufacturing populations. Sometimes I think such strong opposition breeds enthusiasm among advocates!
It certainly breeds creativity--Kentucky was one of the first (if not the first) states where a complaint was filed under the federal Americans with Disabilities Act (ADA), which got a large university basketball stadium and several other venues to eventually go smoke-free "voluntarily."

By contrast, Virginia, where I live, has very little going on--people seem to have accepted smoky public places as a fact of life (though from what I've seen, VA is somewhat better on youth access-type issues).

And proximity doesn't necessarily have much to do with it--Maryland, right next door to Virginia (and also a tobacco-producing state), has a strong coalition, a Governor who supports raising the tobacco tax, another ADA lawsuit pending, and one of few counties in the nation to pass a 100% smokefree restaurant and bar ordinance. West Virginia, also nearby, is another leader in passing local anti-tobacco ordinances.

And then there are those states where advocates are steadfastly working away against the problem of tobacco use, and making strong gains while receiving relatively little publicity for their successes.

Among these I would include Nebraska, Hawaii, Alaska, Vermont, Illinois, New York, Utah, North Dakota, Wisconsin, Washington, Michigan, Iowa--in fact, I believe most states have some level of positive activity, but too often we don't hear about the small-scale successes.

4. Prohibiting smoking in public places is a very effective way to promote tobacco control. It sometimes/often provokes controversy -as the tobacco industry strongly opposes such measures-.
From your experience, what advice would you give to cities when they have to address this problem. What advice could you give -for instance- to the city of Paris (France) to improve enforcement of the smoke-free regulations in cafes? Since I mentioned Paris, do you have international contacts with cities and counties in other countries?

From my experience in speaking with local advocates and those from organizations like Americans for Nonsmokers' Rights, the main thing is to build a base of community support for smoke-free public places before you approach policy makers.

Educate community members about the health effects of secondhand smoke. Collect polling data (or, if the community already seems receptive to the idea, petition signatures) in the community to demonstrate citizens' desire for clean indoor air. Approach restaurant owners with the idea, and ask them to voluntarily go smoke-free--even just to try it for a day.

Offer whatever free publicity you can--provide "Proud to be smokefree"
signage, publish a local "Smokefree dining guide," and thank them for their open-mindedness in a public way.

Provide them with the strong scientific evidence that going smoke-free doesn't hurt business, but does help their patrons and workers be healthier.

Ideally, all of these types of activities should happen before any ordinance or legislation is introduced. Once you can demonstrate community support for the idea, policymakers will have no legitimate reason to reject the idea.

Of course, the key word in that sentence is "legitimate"--as always, advocates must be vigilant about opposition drummed up by the tobacco industry.

Keep an eye out for their operatives, who typically seem to work through restaurant associations and the like, and who will also attempt to overwhelm local officials with bad research and bogus arguments about lost business, difficulty of enforcement, etc.

While I'm on this topic, I have to offer a strong endorsement of Americans for Nonsmokers' Rights and their services, at least for those advocates working in the U.S.

I'm only giving a tiny capsule of advice here, but ANR is an excellent resource and practically wrote the book on passing local ordinances.

They have a database of ordinances, reams of information on tobacco industry shenanigans, and the ability to reach out and assist communities interested in pursuing tobacco-free policies of all kinds.)

In answer to your next question, I must admit I may not be the best person to give you advice on the city of Paris, especially in terms of enforcing smoking bans. In the U.S., most often it seems that non-smoking rules (even those that are self-imposed by restaurant or other venue owners) are self-enforcing--once people get used to breathing clean air, they are reluctant to stop!

My understanding of the situation in much of Europe these days (though PLEASE tell me if I am assuming incorrectly) is that there is a much less strong non-
smoking social norm, despite the fact that the majority of individuals are non-smokers. Changing that social norm--helping people understand that most people don't smoke, that people's smoking harms those around them, and empowering citizens to challenge those who smoke in ostensibly smoke-free places--is probably the most effective way to address the "enforcement" of non-smoking rules.

Then the social norm should be backed up by law enforcement, if necessary.

In terms of international contacts, I do have a few scattered around. Virtually all of them were made through GlobaLink, in fact! So far I have not formally collaborated with any of them, other than to exchange some information, but in the future...who knows?
I am planning to try to attend the World Conference in 2000.

5. Being active in tobacco control means you alienate the tobacco industry that is a very powerful lobby. Are there cases of city or county officials who face(d) problems because of their involvement in tobacco control, like recently the "forced resignation" of the tobacco control program Director in Florida?

I think that there can absolutely be some problems with this issue.

It tends to happen more on the State level, where tobacco control activities are more visible, and where the tobacco industry holds a great deal more influence.

At the local level, politicians are much more accountable to the community, so that the industry has had difficulty gaining the kind of influence that would cause a local health official to be fired or otherwise formally disciplined for working to reduce tobacco use.

That said, however, there can be sticky situations--I have heard of one health official who was once asked by his boss not to speak out in support of a strong smokefree ordinance, mostly because it would be politically problematic for the boss, while at the same time local advocates and the media were asking for the official's stance.

As far as I know nothing untoward happened to the official, but it did make for an uncomfortable situation.

In some States, local health officials are actually State employees and technically even political appointees, and theoretically could therefore be "unappointed" by Governors who opposed strong tobacco control measures (in fact, this is the case in Florida).

What you feel like adding :

Thanks for the opportunity to respond to these questions! It was very thought provoking and enjoyable. However, I would like to make it clear that any opinions I have expressed are mine alone, and do not necessarily represent NACCHO's policy as an organization.

Also, I will be happy to answer any other questions that fellow GlobaLinkers may have about local health departments' involvement in tobacco control.

Thank you Amanda for taking the time to be with us today.